08/07/1996 49230

HIPP OPERATIONS SPECIALIST

DEFINITION: This is technical work in determining the cost effectiveness of alternative health care programs for eligible medical assistance recipients under the Department of Public Welfare's Health Insurance Premium Payment (HIPP) Program.

Employees in this class are responsible for determining the cost effectiveness of initiating Employer Group Health Program (EGHP) and Medicare Supplement A/(Medigap) Insurance applications, enrolling eligible Medical Assistance recipients into employer group health insurance plans, and for the purchase, administration, and maintenance of the Department's Medigap Insurance Program for cost effective, dually eligible Medicare/ Medicaid recipients. Employees analyze and compare the insurance premiums for specified coverage against the projected annual Medical Assistance expenditures for the Medical Assistance recipient based upon a cost matrix; negotiate with employers, unions, and/or insurance carriers on behalf of recipients to resolve issues, establish premium payment methodology, enrollment dates, and policy changes; and educate employers, insurance carriers, county assistance office (CAO) workers, medical providers, and other interested parties regarding HIPP activities, Federal laws, and their participation. Employees cite policies, laws and interpretations which govern the HIPP Program and the legal responsibilities of employers, insurance companies, and the Commonwealth. Work involves representing the Commonwealth's rights, identifying insurance providers who refuse to cooperate, determining if a case should be referred to the Department's Office of Legal Counsel for resolution, authorizing the Comptroller's Office to release payment for the premiums, and researching returned checks and processing via the Comptroller's Office. Work is reviewed by a HIPP Operations Specialist Supervisor or administrative supervisor through review of completed work and reports, and/or monitoring as required.

EXAMPLES OF WORK: Reviews referrals to enroll eligible Medical Assistance recipients into EGHPs or Medigap programs for appropriateness, verifies Medical Assistance eligibility for all potential covered household members, checks for deadlines, and identifies special conditions, SSI related categories and COBRA cases.

Develops and documents each referral case, outlining the steps taken to determine eligibility and establish payments to create an audit trail for responses to appeals.

Analyzes and evaluates employer group health plans, policies and employee benefit booklets to determine insurance coverage available to Medical Assistance recipients.

Identifies the premium payments and enters information into a computer program to determine whether it is cost effective to enroll the recipient in an EGHP and/or a Medigap program.

Researches Pennsylvania insurance laws, specific policy coverage and recipient eligibility provisions to determine the cost effectiveness of a policy and in relation to the HIPP Program.

Determines the effective date of eligibility for the HIPP Program to correspond with the effective date of coverage for the insurance premium payment; negotiates with employers, unions, and insurance carriers to establish the payment methodology and the effective dates of policy coverage.

Applies, interprets, and cites various laws, regulations, and policies in order to negotiate successfully with employers, unions, and private insurance companies.

Purchases Medigap insurance for dually eligible Medicare/Medicaid recipients when cost effective; reconciles payments for Medigap coverage, returned monies from the carriers, and maintains a payment report as an audit trail for all transactions.

Tracks all recipients enrolled in EGHP and/or Medigap programs and manages premium payment information to generate insurance payments in a timely manner to the proper payee.

Maintains the HIPP Premium Payment/MEDIGAP System by entering recipient eligibility information with corresponding premium payment information, as well as cancelling premium payments and eligibility when determination is made that a policy has been cancelled, is no longer cost effective, or a recipient loses eligibility for Medical Assistance benefits.

Maintains HIPP information on a TPL data base for resources established through the HIPP Program.

Responds to telephone and written inquiries from insurance carriers, Medical Assistance recipients, CAO staff, inter and intra-departmental agencies, and other interested parties, explaining the administrative process and procedures for participation in the HIPP Program, the enrollment processes, and the cost effectiveness determination process.

Prepares statistical reports relative to the cost effectiveness of enrolling eligible Medical Assistance recipients into EGHP and/or a Medigap program.

Maintains Medigap premium charts by updating rate changes.

Educates referral sources such as, but not limited to, hospitals, nursing homes, and other public and private agencies of the HIPP Program to ensure they refer potentially eligible recipients for consideration.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES: Knowledge of federal and state rules, regulations, policies, and procedures relating to the various aspects of the Medical Assistance Program, HIPP Program, state insurance laws, and the requirements of the Health Care Financing Administration (HCFA).

Knowledge of the methods, processes, and procedures for eligibility determination and negotiating policies and premium payments for Medical Assistance recipients with employers, unions, and insurance carriers.

Knowledge of provisions, health care eligibility criteria, and the billing and provider agreements relating to Medicare, Medicaid, Blue Shield and Blue Cross, DPW contracted managed care health plans, and commercial health care.

Knowledge of medical terminology, sufficient to read and comprehend medical reports.

Knowledge of resources for researching and obtaining information for case documentation, such as the MAMIS and TPL automated system files, health care providers, and insurance companies.

Ability to identify, gather, clarify, and explain information requested by, or required from, the various health care providers, private insurers, and other involved parties.

Ability to apply methods, techniques, and procedures for evaluating and determining the cost effectiveness of EGHP and Medigap applications from Medical Assistance recipients.

Ability to establish and maintain cooperative working relationships with Medical Assistance recipients, private insurance carriers, public and private officials, CAO staff, domestic relations office staff, attorneys, and associates.

Ability to effectively communicate orally and in writing.

MINIMUM EXPERIENCE AND TRAINING: One year of experience as a Third Party Liability or Medical Assistance Program Technician;

                                                                                                                                                                         or

Four years of experience in the review and analysis of medical insurance policies and premiums, reviewing and responding to inquiries relating to applicable service or benefits in health care insurance programs, health care services or Medical Assistance program services.

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Any equivalent combination of experience and training.